- Email: [email protected]
THE M.R.C. IN WAR
718
logical, implicit in fixing the size of the family." Surely we can with equanimity and with economy leave young couples to decide, not in advance but as they go along, how many children they want. It is far more important to see that those who decide in favour of children are not, relatively speaking, so much worse off in material things compared with their friends and neighbours who remain childless. For some years to come the major problem of family economics will revolve round the need for greater production (and therefore more women in factories, shops, and offices) as against the need for a steady supply of babies to prevent a future decline in the total population and a worsening in the balance of youth and old age. It is a pity, therefore, that this otherwise valuable report from- P.E.P. fails to face this issue in a realistic and forthright manner.
The Plebiscite of the plebiscite, analysed by
THE results groups, will be found in detail on another page. Of the doctors who returned their forms by last Monday 14,620 (36%) approve of the National Health Service Act " in view of the modifications now proposed by the Government," while 25,842 (64%) disapprove. Historians will note that the profession has deliberately recorded its opposition to the new measure. On the practical question whether service under the Act should be accepted, the voting among those chiefly affected is nearly equal, 12,799 (48%) being in favour and 13,891 (52%) against. The number of general practitioners and assistants who are against service is 9588 (compared with 17,037 in the previous plebiscite), and is thus several thousand short of the figure of approximately 13,000 which the British Medical Association council formerly thought necessary for effective opposition. It is true that 11,885 principals and assistants express their willingness to abide by the decision of a sufficient majority ; but the majority, by previous definition, is insufficient. The B.M.A. council has the satisfaction of seeing its slightly negative lead translated faithfully into a slightly negative vote, but organised resistance to the Act seems to be no longer possible. We earnestly hope that the profession will adopt the only sane alternative -an organised effort to make it work. Those who are not actively against the service must in the end be actively for it, and the sooner this is recognised the better. Long hesitation followed by vigorous action is, after all, in the best English tradition, well illustrated in the late war. Writing of the preparations for the invasion of France in 1944, an American staff officer has described how during many disheartening months his British counterparts seemed to see nothing but obstacles. But when the final decision was reached their attitude changed overnight; their whole mind was now set on success for the plan adopted,, and difficulties became incidental. Nobody at all can be satisfied with a verdict so evenly divided, and the objections of the majority can be dispelled only by active cooperation in the new atmosphere created by the Minister’s statement on April 7. As future partners in what is, after all, a great if rather hazardous enterprise, our representatives can work with the Minister on a new footing, and by friendly discussion of certain important details much can be done to restore confidence before the appointed day.
Annotations THE DURING the last
M.R.C.
IN
WAR
century medical science
has earned
in national affairs; and this has never been more evident than in the late war, when it fell to doctors not only to treat the sick and wounded but also to promote the efficiency of the fighting Forces and the civilians who sustained them, and to maintain the population-in full health. In this work the Medical Research Council played its part by advice to Government departments and the Services, by research into problems of immediate importance, and by devising and administering emergency services ; and the M.R.C.’s own account 1 reminds us how well these duties were a
responsible place
discharged. From the start the prevention of undernutrition was recognised as the keystone to the structure of national defence ; and perhaps the most important result of expert medical guidance was the continuance, despite attenuated supplies, of the people’s capacity to work and fight. Much of the council’s advisory work consisted in drawing- attention to earlier investigations which had passed unnoticed ; and the report observes that with proper appreciation of previous studies of vocational it might have been selection and accident-proneness possible to avoid the introduction of those excessively strenuous working conditions in the period immediately following the evacuation of Dunkirk which proved .’ incompatible with a large sustained output from the factories and with a good standard of health among the workpeople." Personnel research committees, representing the new and active role of medicine in war, were formed and attached to each of the three Service departments. Engaged largely in environmental research, they aimed to fit the machine to man rather than man to the machine. Their experience can well be turned to peaceful purposes ; and the report expresses the hope that whenever in the future new problems " involving the design and development of instruments, weapons and machinery, which have to be worked by human beings, arise, it will no longer be thought sufficient to have such matters considered only by engineers and physicists." The council was largely concerned with the risk of infectious diseases ; and this was one of the principal considerations leading to the establishment of the Emergency Public Health Laboratory Service. For the protection of Service people new vaccines and inocula, new drugs, and particularly new chemotherapeutic agents were devised. These agents had an important "
influence on war surgery ; thanks to them and ’the surgical methods that they made possible, of the British soldiers who came into the hands of the medical service after being wounded in the north-west Europe campaign of 1944-45 only 7% died. On the whole, surgical advances were less notable in technique, which had been explored in the earlier war, than in the vital ancillariesanaesthesia, the prevention and treatment of shock and of infection, and reablement. One effect of these improvements was to give greater latitude to the operator, especially in plastic surgery and the surgery of head and chest. The common need and the pall of " security " which descended even on medical research drew the workers of the Allied nations together ; and many of the advances derived from integrated international effort. The fruits of war-time research were won by concentration of resources on immediate problems and by reduction of the time-lag between discovery and application. Many of the ad-hoc studies were based on fundamental investigations undertaken in the measured tempo of 1. Medical Research in War: Report of the Medical Research Council for the Years 1939-45. Cmd. 7335. H.M. Stationery Office. Pp. 455. 7s. 6d.
719 peace ; and report says :
by
1945 this
source was
running dry.
The
carried out, and that established rules and regulations enforced ; what the hospitals need is an executive capable of initiating measures to fit the hospitals’ program accurately to the needs of the community." A trained superintendent, yes : but absolute hierarchy, certainly not. A quotation from Florence Nightingale’s Notes on Hospitals is invoked : are are
"There comes a time when the research worker has to decide whether to confine his interests to giving limited answers or to delve deeper, and inevitably more slowly, to obtain a fuller grasp of the principles involved. So it is that, although war acts at first as an intense stimulus to certain branches of- medical ’research, in the long run it tends to lose its effect as an incentive to discovery." Between 1940 and 1945 the grants-in-aid made by Parliament to the council grew from il95,000 to £295,000 Was ever money better spent ? a year. ’
HUMANITY IN HOSPITALS Dr. S. S. Goldwater died in 1942, revered by the American hospital world. He went to work in his early teens; but later returned to school and to the universities of and Leipzig, where he studied economics, philosophy, and ethics.’ He then recognised his passion for improvement in the order of society, and decided that medicine would afford him the solid ground for an approach to a better world. Graduating from New York University College of Medicine in 1901, he soon had to face the choice between clinical medicine and administration. His imagination was captured by the hospital as an institution, " a strange, fascinating, forbidding mixture of elevating and depressing elements " ; but little prestige then attached to the position of hospital superintendent, and his fellow interns were surprised when Goldwater applied for the position of assistant superintendent then vacant. Thenceforward he became identified with the Mount Sinai Hospital, of which he was administrator from 1902 to 1929, later filling other prominent posts in the hospital world of New York. In 1908 he was chosen president of the American Hospital Association, for his advice was already being widely sought. He was consulted by Chicago on a plan for a hospital of 4000 beds, and succeeded in arousing the leading citizens to the enormity of five or six miles of sick beds under one management, an ungovernable mass which spells outrage and disaster." A little later at Philadelphia, plans for a great conglomeration of poorhouse, home for the aged, orphanage, insane asylum, hospital and what not were referred to him, and Goldwater "with all the courtesy in the world cast the plans into the rubbish heap." His later life was an unending round of consultation, and advice given in many directions. A brief account of Goldwater’s life and a selection of his writings1 affords a running commentary on the great creative period of American hospitals in the first three decades of the present century. He was always suspicious of the tendency to increase the size of the institution, and the reader will wonder how he would have viewed the present tendency in Britain to entrust several hospitals to the control of a single hospital management committee :e
"
In our imperfect state of conscience and enlightenment, publicity, and the collision resulting from publicity, are the best guardians of the interests of the sick. A patient is
much better cared for in an institution where there is the perpetual rub between doctors and nurses, between students, matrons, governors, treasurers, and casual visitors, between secular and spiritual authorities, than in a hospital under the best governed order in existence, where the chief of that order, be it male or female, is also chief of the hospital. Taking the imperfect general run of human things, for we are considering men and not angels, public opinion is a higher average standard than individual opinion."
Columbia
"
" In cities of moderate size," he said, " consolidated seems to be the simplest method of handling the matter. In very large communities, however, the management of many large institutions from a central office may result disastrously, unless each institution to the system is granted a large measure of local autonomy with respect to its internal affairs. The problem here is the familiar one of maintenance of the individuality of an institution, stimulation of local pride, encouragement of healthy rivalry, development of a keen sense of responsibility, and especially the fostering of warm personal devotion, without which the morale of an institution is speedily impaired.... The duplication of medically efficient and physically economical units is perfectly sound practice, and should not be discouraged by central hospital
management
belonging
authorities."
He was a vigorous advocate of training in hospital administration :" what the hospitals ask for is a superintendent who will see that the policies of the trustees 1. On
Hospitals.
By S. S. GOLDWATER, M.D. 1947. Pp. 395. 45s.
London’: Macmillan.
New York and
Goldwater thought Notes on Hospitals a document that every student of hospitals should read at least once a year-" for boldness of aim, warmth of expression, and breadth of view, it has no equal in hospital literature." Though his copious essays do not lend themselves to summary, these few quotations may suffice to show the stature of one of the men responsible for making the American hospital world the living thing that it is today. DIAGNOSIS OF DISSECTING ANEURYSM DISSECTING aneurysms of the aorta
are most often the post-mortem table, but, though-they are much rarer than cerebrovascular accidents or myocardial infarction as a cause of sudden collapse or coma, there is now sufficient evidence for a diagnosis to be possible during life. Of the 44 cases reviewed by Baer and Goldburgh,l 11 were diagnosed before death. The recorded incidence varies, according to the source of the information. Thus, in medicolegal reports on sudden deaths an incidence of 1-1% has been recorded,2 whereas in general necropsies the incidence ranges from 1 in 480 to 1 in 431.4 It is predominantly a condition of middle-aged or elderly men. In his classical monograph Shennan5 noted that over 80% of cases occurred over the age of fifty years, with 65% in men. Baer and Goldburgh give similar figures-76-5% over fifty and 66% males. The typical picture closely resembles coronary thrombosis, with sudden severe pain and intense dyspncea, but in 24 of the 44 cases collected by Baer and Goldburgh there was no record of pain throughout the patient’s illness. - If the patient survives the immediate rupture the most common ofJigns are pyrexia, tachyéardia, and dyspnoea, often with a polymorph leucocytosis, all of which will fit in with the commonly made diagnosis of myocardial infarction or an acute abdominal catastrophe. As a rule the pain is mainly epigastric, and it may even be accompanied by haematemesis or melaena if the gastric or mesenteric vessels are involved, but there is usually no history suggestive of peptic ulcer or carcinoma of the stomach. The electrocardiogram is not characteristic, though in view of the age-incidence there may well be changes pointing to coronary disease. A haemorrhagic hydrothorax should raise suspicions of dissecting
diagnosed
on
Hypertension is present in most cases, but a fall in pressure is usual at the time of the catastemporary trophe. An aortic diastolic murmur appears in a minority of cases, and the development of cardiac or aortic enlargement is a useful diagnostic finding in patients who survive. Bizarre neurological signs, presumably due to involvement of the intercostal, lumbar, or femoral aneurysm.
Baer, S., Goldburgh, H. L. Amer. Heart J. 1948, 35, 198. Mote, C. D., Carr, J. L. Ibid, 1942, 24, 65. Gouley, B. A., Anderson, E. Ann. intern. Med. 1940, 14, 978. Glendy, R. E., Castleman, B., White, P. D. Amer. Heart J. 1937, 13, 129. 5. Shennan, T. Dissecting Aneurysms. Spec. Rep. Ser. med. Res. Coun., Lond. no. 193, 1934. See Lancet, 1934, i, 470. 1. 2. 3. 4.
logical, implicit in fixing the size of the family." Surely we can with equanimity and with economy leave young couples to decide, not in advance but as they go along, how many children they want. It is far more important to see that those who decide in favour of children are not, relatively speaking, so much worse off in material things compared with their friends and neighbours who remain childless. For some years to come the major problem of family economics will revolve round the need for greater production (and therefore more women in factories, shops, and offices) as against the need for a steady supply of babies to prevent a future decline in the total population and a worsening in the balance of youth and old age. It is a pity, therefore, that this otherwise valuable report from- P.E.P. fails to face this issue in a realistic and forthright manner.
The Plebiscite of the plebiscite, analysed by
THE results groups, will be found in detail on another page. Of the doctors who returned their forms by last Monday 14,620 (36%) approve of the National Health Service Act " in view of the modifications now proposed by the Government," while 25,842 (64%) disapprove. Historians will note that the profession has deliberately recorded its opposition to the new measure. On the practical question whether service under the Act should be accepted, the voting among those chiefly affected is nearly equal, 12,799 (48%) being in favour and 13,891 (52%) against. The number of general practitioners and assistants who are against service is 9588 (compared with 17,037 in the previous plebiscite), and is thus several thousand short of the figure of approximately 13,000 which the British Medical Association council formerly thought necessary for effective opposition. It is true that 11,885 principals and assistants express their willingness to abide by the decision of a sufficient majority ; but the majority, by previous definition, is insufficient. The B.M.A. council has the satisfaction of seeing its slightly negative lead translated faithfully into a slightly negative vote, but organised resistance to the Act seems to be no longer possible. We earnestly hope that the profession will adopt the only sane alternative -an organised effort to make it work. Those who are not actively against the service must in the end be actively for it, and the sooner this is recognised the better. Long hesitation followed by vigorous action is, after all, in the best English tradition, well illustrated in the late war. Writing of the preparations for the invasion of France in 1944, an American staff officer has described how during many disheartening months his British counterparts seemed to see nothing but obstacles. But when the final decision was reached their attitude changed overnight; their whole mind was now set on success for the plan adopted,, and difficulties became incidental. Nobody at all can be satisfied with a verdict so evenly divided, and the objections of the majority can be dispelled only by active cooperation in the new atmosphere created by the Minister’s statement on April 7. As future partners in what is, after all, a great if rather hazardous enterprise, our representatives can work with the Minister on a new footing, and by friendly discussion of certain important details much can be done to restore confidence before the appointed day.
Annotations THE DURING the last
M.R.C.
IN
WAR
century medical science
has earned
in national affairs; and this has never been more evident than in the late war, when it fell to doctors not only to treat the sick and wounded but also to promote the efficiency of the fighting Forces and the civilians who sustained them, and to maintain the population-in full health. In this work the Medical Research Council played its part by advice to Government departments and the Services, by research into problems of immediate importance, and by devising and administering emergency services ; and the M.R.C.’s own account 1 reminds us how well these duties were a
responsible place
discharged. From the start the prevention of undernutrition was recognised as the keystone to the structure of national defence ; and perhaps the most important result of expert medical guidance was the continuance, despite attenuated supplies, of the people’s capacity to work and fight. Much of the council’s advisory work consisted in drawing- attention to earlier investigations which had passed unnoticed ; and the report observes that with proper appreciation of previous studies of vocational it might have been selection and accident-proneness possible to avoid the introduction of those excessively strenuous working conditions in the period immediately following the evacuation of Dunkirk which proved .’ incompatible with a large sustained output from the factories and with a good standard of health among the workpeople." Personnel research committees, representing the new and active role of medicine in war, were formed and attached to each of the three Service departments. Engaged largely in environmental research, they aimed to fit the machine to man rather than man to the machine. Their experience can well be turned to peaceful purposes ; and the report expresses the hope that whenever in the future new problems " involving the design and development of instruments, weapons and machinery, which have to be worked by human beings, arise, it will no longer be thought sufficient to have such matters considered only by engineers and physicists." The council was largely concerned with the risk of infectious diseases ; and this was one of the principal considerations leading to the establishment of the Emergency Public Health Laboratory Service. For the protection of Service people new vaccines and inocula, new drugs, and particularly new chemotherapeutic agents were devised. These agents had an important "
influence on war surgery ; thanks to them and ’the surgical methods that they made possible, of the British soldiers who came into the hands of the medical service after being wounded in the north-west Europe campaign of 1944-45 only 7% died. On the whole, surgical advances were less notable in technique, which had been explored in the earlier war, than in the vital ancillariesanaesthesia, the prevention and treatment of shock and of infection, and reablement. One effect of these improvements was to give greater latitude to the operator, especially in plastic surgery and the surgery of head and chest. The common need and the pall of " security " which descended even on medical research drew the workers of the Allied nations together ; and many of the advances derived from integrated international effort. The fruits of war-time research were won by concentration of resources on immediate problems and by reduction of the time-lag between discovery and application. Many of the ad-hoc studies were based on fundamental investigations undertaken in the measured tempo of 1. Medical Research in War: Report of the Medical Research Council for the Years 1939-45. Cmd. 7335. H.M. Stationery Office. Pp. 455. 7s. 6d.
719 peace ; and report says :
by
1945 this
source was
running dry.
The
carried out, and that established rules and regulations enforced ; what the hospitals need is an executive capable of initiating measures to fit the hospitals’ program accurately to the needs of the community." A trained superintendent, yes : but absolute hierarchy, certainly not. A quotation from Florence Nightingale’s Notes on Hospitals is invoked : are are
"There comes a time when the research worker has to decide whether to confine his interests to giving limited answers or to delve deeper, and inevitably more slowly, to obtain a fuller grasp of the principles involved. So it is that, although war acts at first as an intense stimulus to certain branches of- medical ’research, in the long run it tends to lose its effect as an incentive to discovery." Between 1940 and 1945 the grants-in-aid made by Parliament to the council grew from il95,000 to £295,000 Was ever money better spent ? a year. ’
HUMANITY IN HOSPITALS Dr. S. S. Goldwater died in 1942, revered by the American hospital world. He went to work in his early teens; but later returned to school and to the universities of and Leipzig, where he studied economics, philosophy, and ethics.’ He then recognised his passion for improvement in the order of society, and decided that medicine would afford him the solid ground for an approach to a better world. Graduating from New York University College of Medicine in 1901, he soon had to face the choice between clinical medicine and administration. His imagination was captured by the hospital as an institution, " a strange, fascinating, forbidding mixture of elevating and depressing elements " ; but little prestige then attached to the position of hospital superintendent, and his fellow interns were surprised when Goldwater applied for the position of assistant superintendent then vacant. Thenceforward he became identified with the Mount Sinai Hospital, of which he was administrator from 1902 to 1929, later filling other prominent posts in the hospital world of New York. In 1908 he was chosen president of the American Hospital Association, for his advice was already being widely sought. He was consulted by Chicago on a plan for a hospital of 4000 beds, and succeeded in arousing the leading citizens to the enormity of five or six miles of sick beds under one management, an ungovernable mass which spells outrage and disaster." A little later at Philadelphia, plans for a great conglomeration of poorhouse, home for the aged, orphanage, insane asylum, hospital and what not were referred to him, and Goldwater "with all the courtesy in the world cast the plans into the rubbish heap." His later life was an unending round of consultation, and advice given in many directions. A brief account of Goldwater’s life and a selection of his writings1 affords a running commentary on the great creative period of American hospitals in the first three decades of the present century. He was always suspicious of the tendency to increase the size of the institution, and the reader will wonder how he would have viewed the present tendency in Britain to entrust several hospitals to the control of a single hospital management committee :e
"
In our imperfect state of conscience and enlightenment, publicity, and the collision resulting from publicity, are the best guardians of the interests of the sick. A patient is
much better cared for in an institution where there is the perpetual rub between doctors and nurses, between students, matrons, governors, treasurers, and casual visitors, between secular and spiritual authorities, than in a hospital under the best governed order in existence, where the chief of that order, be it male or female, is also chief of the hospital. Taking the imperfect general run of human things, for we are considering men and not angels, public opinion is a higher average standard than individual opinion."
Columbia
"
" In cities of moderate size," he said, " consolidated seems to be the simplest method of handling the matter. In very large communities, however, the management of many large institutions from a central office may result disastrously, unless each institution to the system is granted a large measure of local autonomy with respect to its internal affairs. The problem here is the familiar one of maintenance of the individuality of an institution, stimulation of local pride, encouragement of healthy rivalry, development of a keen sense of responsibility, and especially the fostering of warm personal devotion, without which the morale of an institution is speedily impaired.... The duplication of medically efficient and physically economical units is perfectly sound practice, and should not be discouraged by central hospital
management
belonging
authorities."
He was a vigorous advocate of training in hospital administration :" what the hospitals ask for is a superintendent who will see that the policies of the trustees 1. On
Hospitals.
By S. S. GOLDWATER, M.D. 1947. Pp. 395. 45s.
London’: Macmillan.
New York and
Goldwater thought Notes on Hospitals a document that every student of hospitals should read at least once a year-" for boldness of aim, warmth of expression, and breadth of view, it has no equal in hospital literature." Though his copious essays do not lend themselves to summary, these few quotations may suffice to show the stature of one of the men responsible for making the American hospital world the living thing that it is today. DIAGNOSIS OF DISSECTING ANEURYSM DISSECTING aneurysms of the aorta
are most often the post-mortem table, but, though-they are much rarer than cerebrovascular accidents or myocardial infarction as a cause of sudden collapse or coma, there is now sufficient evidence for a diagnosis to be possible during life. Of the 44 cases reviewed by Baer and Goldburgh,l 11 were diagnosed before death. The recorded incidence varies, according to the source of the information. Thus, in medicolegal reports on sudden deaths an incidence of 1-1% has been recorded,2 whereas in general necropsies the incidence ranges from 1 in 480 to 1 in 431.4 It is predominantly a condition of middle-aged or elderly men. In his classical monograph Shennan5 noted that over 80% of cases occurred over the age of fifty years, with 65% in men. Baer and Goldburgh give similar figures-76-5% over fifty and 66% males. The typical picture closely resembles coronary thrombosis, with sudden severe pain and intense dyspncea, but in 24 of the 44 cases collected by Baer and Goldburgh there was no record of pain throughout the patient’s illness. - If the patient survives the immediate rupture the most common ofJigns are pyrexia, tachyéardia, and dyspnoea, often with a polymorph leucocytosis, all of which will fit in with the commonly made diagnosis of myocardial infarction or an acute abdominal catastrophe. As a rule the pain is mainly epigastric, and it may even be accompanied by haematemesis or melaena if the gastric or mesenteric vessels are involved, but there is usually no history suggestive of peptic ulcer or carcinoma of the stomach. The electrocardiogram is not characteristic, though in view of the age-incidence there may well be changes pointing to coronary disease. A haemorrhagic hydrothorax should raise suspicions of dissecting
diagnosed
on
Hypertension is present in most cases, but a fall in pressure is usual at the time of the catastemporary trophe. An aortic diastolic murmur appears in a minority of cases, and the development of cardiac or aortic enlargement is a useful diagnostic finding in patients who survive. Bizarre neurological signs, presumably due to involvement of the intercostal, lumbar, or femoral aneurysm.
Baer, S., Goldburgh, H. L. Amer. Heart J. 1948, 35, 198. Mote, C. D., Carr, J. L. Ibid, 1942, 24, 65. Gouley, B. A., Anderson, E. Ann. intern. Med. 1940, 14, 978. Glendy, R. E., Castleman, B., White, P. D. Amer. Heart J. 1937, 13, 129. 5. Shennan, T. Dissecting Aneurysms. Spec. Rep. Ser. med. Res. Coun., Lond. no. 193, 1934. See Lancet, 1934, i, 470. 1. 2. 3. 4.